ACCIDENT INFORMATION REPORT
Return to Lucille Genovese, Benefits Administration +0602
A. THIS SECTION TO BE COMPLETED & SIGNED BY EMPLOYEE LAST NAME – FIRST NAME – MIDDLE NAME Employee ID# DATE OF BIRTH SEX DATE & TIME OF INCIDENT
HOME ADDRESS
PHONE NUMBER
DEPT NAME
REPORTED TO DEPT SUPERVISOR DATE TIME LOCATION OF ACCIDENT (Be Specific)
JOB TITLE
LOST TIME
RETURN DATE
____ YES ____NO EMPLOYEE’ S STATEMENT - INDICATE HOW, WHEN, WHERE INJURY OCCURRED & DESCRIBE PART OF BODY INJURED
NATURE OF INJURY ___ FRACTURE ___ STRAIN/SPRAIN ___ FOREIGN BODY NAME OF WITNESSES: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ___ LACERATION ___ BURN ___ OTHER
WAS FIRST AID GIVEN? _____ YES _____ NO DID YOU GO TO DOCTOR? _____ YES _____ NO, IF YES GIVE NAME _________________________________________________________________________ DID YOU GO TO HOSPTIAL? _____ YES _____NO, IF YES GIVE NAME _________________________________________________________________________ HAVE UP FILED FOR WORKER’S COMPENSATION BEFORE? _____ YES _____ NO, IF YES, WHERE ______________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
I, the injured employee, herein certify that the information set forth above is true and correct to the best of my knowledge. _________________________________________________________ _______________________________ Employee’s Signature Date Signed B. THIS SECTION TO BE COMPLETED & SIGNED BY SUPERVISOR
DESCRIPTION AND APPARENT CAUSE OF ACCIDENT _____________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________ IF PROPERTY/EQUIPMENT INVOLVED, DESCRIBE DAMAGE _____________________________________________________________________________________________________________________________________________ WHAT WAS INJURED DOING WHEN INCIDENT OCCURRED? _____________________________________________________________________________________________________________________________________________ CORRECTIVE ACTION RECOMMENDED _____________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________ WAS ACCIDENT DUE TO UNSAFE EQUIPMENT OR CONDITION? _____________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________ ____________________________________________ __________________________________________
Supervisor’s Signature
C. THIS SECTION TO BE COMPLETED BY INVESTIGATOR
Date Signed
HAS INVESTIGATION BEEN MADE _____ YES _____NO, IF YES, ON WHAT DATE? _______________________________________________________________ INVESTIGATIOR’S REMARKS & RECOMMENDATIONS _____________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________ RECOMMENDATION FOR FILING CLAIM __________ APPROVED ___________ DISAPPROVED ______________________________________________ _________________________________________
Investigator’s Signature
Date Signed